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Ovarian torsion in a 14-year-old girl. (a) Transverse gray-scale US image shows an enlarged, predominantly solidappearing torsed right ovary (RO) in the midline posterior to the bladder. Physiologic follicles are seen in the normal small left ovary (LO). The volume of the right ovary is 25 times greater than that of the left ovary. The surgically proven diagnosis was ovarian torsion. (b) Axial non-contrast material-enhanced computed tomographic (CT) image of the pelvis shows a midline to left-sided mass (O) with predominantly central low attenuation, consistent with a torsed right ovary. Free fluid ( * ) and increased attenuation of the anterior pelvic fat (arrows) also are seen.
Source publication
The accurate diagnosis of ovarian torsion is imperative, as loss of the ovary can have long-term consequences in terms of fertility. However, a nonspecific clinical presentation in conjunction with a highly variable imaging appearance makes the diagnosis of ovarian torsion challenging. This is complicated even further in the pediatric population, a...
Contexts in source publication
Context 1
... findings include an enlarged adnexal mass that may be midline or on the contralateral side of the pelvis, a cystic appearance of the torsed ovary, deviation of the uterus to the side of the torsed ovary, and thickening of the fallopian tube (27,49). Peripherally located follicles with an edematous ovarian stroma, poor enhancement of the ovary, adnexal hemorrhage, heterogeneity and increased attenuation of the surrounding fat, plasma erythrocyte levels within the torsed ovary, and/or a twisted vascular pedicle also may be seen (3,27,49,50) (Figs 4b, 7b, 8b, 8c). ...
Context 2
... findings include an enlarged adnexal mass that may be midline or on the contralateral side of the pelvis, a cystic appearance of the torsed ovary, deviation of the uterus to the side of the torsed ovary, and thickening of the fallopian tube (27,49). Peripherally located follicles with an edematous ovarian stroma, poor enhancement of the ovary, adnexal hemorrhage, heterogeneity and increased attenuation of the surrounding fat, plasma erythrocyte levels within the torsed ovary, and/or a twisted vascular pedicle also may be seen (3,27,49,50) (Figs 4b, 7b, 8b, 8c). ...
Citations
... For ovarian torsion, timely surgical management is one of the keys to restore ovarian blood perfusion and reduce the possibility of ovarian necrosis [31] , whose early diagnosis and treatment urgently require a reliable assessment index. B-mode ultrasound is the imaging test of choice for ovarian torsion, which is most often manifested by increased ovarian volume, reduced or even absent blood ow signals, and periventricular follicular ring sign, accompanied by pelvic effusion and the "whirlpool sign", etc [32][33] . However, children are in the stage of growth and development, the ovarian size, morphology and performance under imaging lack of speci city, coupled with the fact that paediatric ovarian torsion is clinically rare, the diagnosis is mostly dependent on the experience of ultrasonographers, and there exists a certain degree of subjective judgement [34][35] , so there is a certain degree of di culty in making a timely and accurate diagnosis of it. ...
Objective To summarize the clinical experience of acute ovarian torsion in girls and to improve clinicians' understanding of the disease.
Methods Retrospective analysis of the clinical data of 6 cases of acute ovarian torsion resulting in ovarian necrosis in girls admitted to the Red Flag Hospital, from January 1, 2016 to February 1, 2023.
Results The age distribution of the six cases was 7-13 years old, with a median of 11 years old, of which three were children with menarches and three were not. The clinical presentation was mainly left lower abdominal, right lower abdominal and periumbilical pain. 4 cases underwent ultrasound or CT examination after the first visit, 2 cases had left ovarian torsion and 4 cases had right ovarian torsion.
Conclusion When girls approaching puberty present with abdominal pain, parents, teachers and their chaperones should be alert to the possibility of common acute abdominal and paediatric gynaecological disorders in children and they need early consultation and ultrasound or CT examination for definitive diagnosis. Early management of paediatric ovarian torsion is very important for the prognosis of the girls, as the rate of removal of the affected ovary is very high if an untimely diagnosis leads to severe local ischaemia and necrosis. Awareness of gynaecological emergencies, early management and training of paediatric surgeons are important to prevent ovarian torsion leading to ovarian necrosis in children and to improve the potential protection of girls' fertility.
... Moreover, torsion symptoms may occur due to venous congestion before arterial supply ceases. Clinically, it is very important to suspect a torsion of the otherwisenormal ovary if we find the enlargement of the ovary, decreased adnexal blood flow, and atypical position of the ovary (22,23) regardless of other findings. In the presented case, the right ovary demonstrated decreased blood flow with collection in the pouch of doglus in the USG on the day of admission. ...
Ovarian torsion can be seen in the otherwise-normal ovary and is a challenging issue in the emergency department. Definitive diagnosis is sometimes difficult to establish because of clinical symptoms similar to other abdominal diseases. We report a 22-year-old woman, nullipara, with acute lower right abdominal pain for 14 hours before coming to an emergency room. On examination, the abdomen was soft but tender over the right iliac fossa and rebound tenderness were present.Ultrasound radiological examination showed that the right ovary is grossly enlarged (volume- 98.4cc) with hyperechoic central stoma. On colour, doppler twisted pedicel was noted. Mild collection is also seen in the pouch of Doglus. During laparoscopy, we found a blackish-red cystic mass of about 12 × 11 cm experiencing torsion. Then salpingooophorectomy was done. This is an interesting case of torsion in an otherwise-normal ovary with a huge hematosalpinx. J Bangladesh Coll Phys Surg 2023; 41(4): 342-347
... Secondly, excision of the cyst to avoid recurrence. Restoration to saline and appreciation of tubal staining is essential [7]. ...
Introduction:
Paratubal cysts are frequent lesions, and may be responsible for complications such as adnexal torsion, which is rare and difficult to diagnose. Management requires emergency surgery in an attempt to preserve the adnexa.
Presentation of case:
We report a rare case of a young patient admitted with a Torsion of paratubal cyst mimicking ovarian torsion, the positive diagnosis was difficult.
Discussion:
Paratubal cysts are lesions that constitute around 10 % of adnexal masses, and may have their embryological origin in Wolfian remnants. Morgagni's hydatid is by far the most common form. Torsion of a para-tubal cyst may manifest as sudden, continuous, or rapidly worsening pain in the iliac fossa. Ultrasound should systematically seek to identify the ovaries outside the lesion. Isolated tubal torsion can only be treated surgically. Laparoscopy is the gold standard.
Conclusion:
Paratubal cyst torsion is rare and very difficult to diagnose, but should be systematically considered in the case of an adolescent presenting with acute pelvic pain.
... However, the characterization of ovarian masses by US alone can be difficult in some cases and may require the use of additional modalities. MRI does not involve the use of ionizing radiation, provides excellent soft tissue contrast and offers the possibility for global abdominopelvic evaluation [3,4,6]. Therefore, it is ideal for the accurate characterization, localization and staging of pediatric ovarian masses. ...
... Therefore, it is ideal for the accurate characterization, localization and staging of pediatric ovarian masses. However, MRI is time-consuming, expensive, has limited availability and may require sedation in younger children [4,6,7]. Consequently, its use in the acute setting is limited [6]. ...
... However, MRI is time-consuming, expensive, has limited availability and may require sedation in younger children [4,6,7]. Consequently, its use in the acute setting is limited [6]. CT, on the other hand, can easily be performed in emergent situations and, despite the radiation use, remains a useful diagnostic modality for the staging of neoplasms and surgical planning due to the aforementioned disadvantages of MRI [4,6]. ...
Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.
... Ovarian engorgement and edema ensue and lead to increased pressure in the ovary. Without intervention, arterial blood supply is compromised and eventually leads to ovarian infarction [9]. The results of several studies have shown that the risk of torsion is correlated with the size of the cysts and is greater when the cysts measure 4 to 5cm [10,11]. ...
... Epidemiologically, fifteen percent 15% of all ovarian torsion occurs in the pediatric population [12,13]. In children, torsion of the ovary can occur at any age, but it predominates in peripuberty and in adolescents with an average age of onset between 9 and 12.5 years [14,9,10,12]. These results can be superimposed on those of our series with respectively 13 and 14 years. ...
... Clinically, adnexal torsion causes acute, intense, unilateral pelvic pain, associated with signs of peritoneal irritation (nausea, vomiting), low-grade fever or dysuria [9,12]. In the presence of a right localization, the adnexal torsion can produce a pseudoappendicular table. ...
Adnexal torsion is a spontaneous rotation of the ovary and sometimes the fallopian tube around its axis which can interfere with arterial supply and lead to ischemia It is a rare complication of an ovarian cyst, which can occur at any age, from the fetal period to adulthood. The mature cystic teratoma accounts for 20% of all ovarian tumors and is seen especially in young girls and therefore is most often benign. It's a surgical emergency. We report here two cases of adnexal torsion operated at the level of the pediatric surgery unit of the Hospital of Mali The two girls are 14 and 13 years old, nulligest and normoregulated with recurrent abdominal pain admitted for acute pelvic pain. On palpation, an abdomino-pelvic mass of a firm and painful consistency is noted. An abdominopelvic ultrasound was performed in both cases and revealed torsion of the left adnexa on the left ovarian cyst in the first and on the right in the second. The surgical procedure performed was manual detorsion and cystectomy in both cases. The anatomopathological examination concluded with a dermoid cyst In the two girls and their postoperative course was simple.
... A meta-analysis has found an overall sensitivity of 92% and a specificity of 96% for the detection of ovarian torsion in pediatrics. This study also indicated that CT has very low sensitivity, making this a poor diagnostic tool for ovarian torsion [17][18]. ...
Ovarian torsion is a rare, emergent occurrence seen in the premenarchal population. If detected promptly, ovarian torsion can be treated via detorsion. We present a case of a three-year-old girl whose ovary spontaneously torsed and was corrected via ovarian detorsion. The patient presented with sudden-onset abdominal pain and emesis; a transabdominal ultrasound with Doppler was performed, which led to the diagnosis of ovarian torsion. The patient was directly taken into surgery for correction, after which she quickly recovered and was subsequently discharged. The choice of ovarian detorsion to protect fertility in pediatric patients is supported by this case and by the related literature. The key to safeguarding fertility in these patients lies in rapid detection, which remains a challenge in the pediatric population. By raising widespread awareness of the use of Doppler ultrasound as well as symptom presentation, the protection of fertility in cases of pediatric ovarian torsion can be improved.
... The torsion of the ovarian pedicle causes the limitation of venous drainage and arterial blood flow, which leads to edema, an inflammatory reaction, ischemia, and eventually necrosis of the tissue. Torsion of the ovarian pedicle can be prevented by avoiding torsion [2,3,4] . The patient initially complaints of abrupt abdominal pain when they arrive at the hospital. ...
... Doppler and grayscale sonography are the primary imaging modalities that are utilised for these individuals during the initial assessment. Other imaging modalities, such as colour Doppler, may also be utilised [3,4] . ...
... These cysts vary in size; they can be simple or complex and are commonly unilateral. Intrauterine and neonatal complications such as torsion and rupture may occur, and treatment options vary from conservative management to antenatal aspiration, early delivery, and neonatal surgery [15]. ...
Midgut volvulus is a life-threatening condition that can lead to bowel ischemia and devastating results with high mortality incidence.
... The best way to see MRI imaging features is on T2-weighted sequences without fat saturation. Hemorrhages can be recognized using fat-saturated T1-weighted lines [14]. ...
An accurate diagnosis of ovarian torsion is critical because of the possible long-term impact on fertility. Ovarian torsion is challenging to diagnose due to a generic clinical presentation and a wide range of imaging appearances. The pediatric group is even more challenging to serve since young people typically fail to define their symptoms or provide a thorough medical history. Imaging is, therefore, critical in diagnosing ovarian torsion in young people. A fourteen-year-old female went to the emergency room complaining of acute left lower quadrant stomach discomfort. She arrived hemodynamically stable with an acute abdomen. Transabdominal ultrasound revealed a primarily anechoic formation spanning 5x5 cm from the left adnexa, with the intact arterial flow but limited lymph node involvement. Transabdominal ultrasound revealed a primarily anechoic formation up to 5x5 cm in size from the left adnexa, with the maintained arterial flow but restricted venous outflow. The patient had an exploratory laparotomy, which revealed a left ovarian cyst (5.2 cm 5.4 cm 2.2 cm) with the left adnexa twisted 720°. The torsion was repaired with a simple cystectomy. Pathology results indicated that the cystic contents were benign. This juvenile patient's ovarian function was preserved thanks to an accurate diagnosis and prompt surgical surgery.
... varian Torsion (OT) has been known as the 5 th most prevalent emergency in the field of gynecology and can result in infertility in case of delayed or inappropriate treatment [1]. OT presents with partial or complete rotation of ligament of ovaries that leads to decreased blood flow, hemorrhagic infarction and necrosis [2,3]. This emergency condition require immediate surgery but the diagnosis might be complicated because of non-specific clinical presentation [4]. ...
Background: Ovarian torsion (OT) is a common gynecological emergency. Clinical presentation is nonspecific, and diagnosis is based on a high index of suspicion. Current recommendations strongly are based on ovarian support.
Objectives: To assess clinical findings and therapeutic approach of patients diagnosed with OT.
Materials and Methods: In this retrospective study 104 patients with confirmed OT in surgery were investigated. Clinical symptoms, laboratory indices, ultrasonography finding, and therapeutic approach were collected from hospital records of patients from 2001 to 2021.
Results: The mean age of patients was 34.7±14.1 years old. The mean duration from hospitalization to surgery was 6.4±3 hours. The most common symptom in patients was abdominal pain (100%) followed by nausea and vomiting (76.9%). Ovarian cyst (71.2%) was the most gynecologic etiology of OT. Local tenderness (92.3%) and rebound tenderness (46.2%) were the most prevalent sign in physical examination. Necrotic ovary was found in 60 patents (57.7%) at surgery. Detorsion was possible in only 26 patients (25%).
Conclusion: This study revealed that most objective findings in patients were nondifferential. The majority of patients with OT were in the reproductive ages, but just one fourth of them treated with conservative management.
